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Spath P, Campana F, Gallitto E, Pini R, Mascoli C, Sufali G, Caputo S, Sonetto A, Faggioli G, Gargiulo M. Impact of iliac access in elective and non-elective endovascular repair of abdominal aortic aneurysm. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:85-98. [PMID: 38635284 DOI: 10.23736/s0021-9509.24.12987-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Endovascular aortic repair (EVAR) is nowadays the establishment treatment for patients with abdominal aortic aneurysm (AAA) both in elective and urgent setting. Despite the large applicability and satisfactory results, the presence of hostile iliac anatomy affects both technical and clinical success. This narrative review aimed to report the impact of iliac access and related adjunctive procedures in patients undergoing EVAR in elective and non-elective setting. Hostile iliac access can be defined in presence of narrowed, tortuous, calcified, or occluded iliac arteries. These iliac characteristics can be graded by the anatomic severity grade score to quantitatively assess anatomic complexity before undergoing treatment. Literature shows that iliac hostility has an impact on device navigability, insertion and perioperative and postoperative results. Overall, it has been correlated to higher rate of access issues, representing up to 30% of the first published EVAR experience. Recent innovations with low-profile endografts have reduced large-bore sheaths related issues. However, iliac-related complications still represent an issue, and several adjunctive endovascular and surgical strategies are nowadays available to overcome these complications during EVAR. In urgent settings iliac hostility can significantly impact on particular time sensitive procedures. Moreover, in case of severe hostility patients might be written off for EVAR repair might be inapplicable, exposing to higher mortality/morbidity risk in this urgent/emergent setting. In conclusion, an accurate anatomical evaluation of iliac arteries during preoperative planning, materials availability, and skilled preparation to face iliac-related issues are crucial to address these challenges.
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Affiliation(s)
- Paolo Spath
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy -
- Unit of Vascular Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy -
| | - Federica Campana
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Enrico Gallitto
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Vascular Surgery, IRCCS University Hospital S. Orsola, Bologna, Italy
| | - Rodolfo Pini
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Vascular Surgery, IRCCS University Hospital S. Orsola, Bologna, Italy
| | - Chiara Mascoli
- Unit of Vascular Surgery, IRCCS University Hospital S. Orsola, Bologna, Italy
| | - Gemmi Sufali
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Stefania Caputo
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Alessia Sonetto
- Unit of Vascular Surgery, IRCCS University Hospital S. Orsola, Bologna, Italy
| | - Gianluca Faggioli
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Vascular Surgery, IRCCS University Hospital S. Orsola, Bologna, Italy
| | - Mauro Gargiulo
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Vascular Surgery, IRCCS University Hospital S. Orsola, Bologna, Italy
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Torsello G, Bertoglio L, Kellersmann R, Wever JJ, van Overhagen H, Stavroulakis K. Three-Year Safety and Efficacy of the INCRAFT Endograft for Treatment of Abdominal Aortic Aneurysms: Results of the INSIGHT Study. J Endovasc Ther 2023:15266028231214162. [PMID: 38031973 DOI: 10.1177/15266028231214162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
PURPOSE Preliminary results of the INSIGHT study showed that the low-profile INCRAFT Abdominal Aortic Aneurysm (AAA) Stent-Graft System was safe and effective in the endovascular aneurysm repair (EVAR). This study aimed to assess the durability and the midterm effectiveness of EVAR using the INCRAFT System in the framework of a multicenter, prospective, open-label, post-approval study. MATERIALS AND METHODS Between 2015 and 2016, 150 subjects from 23 European centers treated with the INCRAFT System for an infrarenal AAA were included. Clinical and radiologic data were prospectively collected and analyzed using protocol-specified, monitored follow-up clinic visits at 1, 6, and 12 months post-implantation and annually after that. The clinical success at 3 years was determined. Freedom from overall and aneurysm-related mortality, type I endoleak, secondary interventions, and aneurysm sac enlargement through 3 years were evaluated. Kaplan-Meier estimates were used for late outcomes. An independent clinical events committee reviewed all events. The CT (computed tomography) scans through 1 year were reviewed by an independent core laboratory. RESULTS The primary clinical success rate at 3 years was 84.0% (126/150). There were no aneurysm-related deaths, endograft migration, or aneurysm-related ruptures through 3 years. Stent fracture was detected in 2 subjects (1.3%) without clinical sequelae. Over 3 years, freedom from overall mortality was 89.4%, freedom from secondary interventions was 80%, and freedom from aneurysm sac enlargement was 96.5%. The 3-year freedom from type IA and IB endoleaks was 93.3% and 98.6%, respectively. CONCLUSIONS. In a multicenter real-world study setting, the use of a low-profile INCRAFT device for AAA is associated with sustained clinical success and low rates of reinterventions through 3 years. CLINICAL IMPACT Low-profile endografts have broadened the spectrum of patients with anatomic suitability for endovascular repair of abdominal aortic aneurysms (AAA). However, questions remain regarding the durability of the repair. The INSIGHT study evaluated the use of the INCRAFT System in routine real-world clinical practice, including patients with complex anatomies. The treatment was safe and effective. The results showed sustained clinical success over 3 years, with no aneurysm-related deaths or ruptures, and a high rate of intervention-free survival at 3 years. Despite the low-profile design of the endograft, the midterm results demonstrate the durability of AAA repair using the INCRAFT System.ClinicalTrials.gov Identifier: NCT02477111.
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Affiliation(s)
- Giovanni Torsello
- Department of Vascular Surgery, St. Franziskus Hospital, Muenster, Germany
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Richard Kellersmann
- Clinic and Polyclinic for General, Visceral, Vascular and Pediatric Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Jan J Wever
- Department of Vascular Surgery & Interventional Radiology, Haga Hospital, The Hague, The Netherlands
| | - Hans van Overhagen
- Department of Vascular Surgery & Interventional Radiology, Haga Hospital, The Hague, The Netherlands
| | - Konstantinos Stavroulakis
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany
- Department of Vascular and Endovascular Surgery, Ludwig-Maximilian-University Hospital, Munich, Germany
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Mazzaccaro D, Righini P, Giannetta M, Galligani M, Milani V, Modafferi A, Malacrida G, Nano G. Low profile endografts for the endovascular treatment of abdominal aortic aneurysms. Expert Rev Med Devices 2023; 20:753-767. [PMID: 37647354 DOI: 10.1080/17434440.2023.2239148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 06/25/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION Favorable midterm outcomes have been reported with the use of low-profile endografts (LPE), but long-term data is still needed. Furthermore, it is unclear if each of these LPE may have advantages over the other, which may, in turn, affect the outcomes. We systematically reviewed the literature about complications and reintervention rates of patients submitted to endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) using LPE. MATHERIALS AND METHODS A literature search was conducted including articles that reported 30-days and follow-up mortality, complications, and reintervention rates of patients treated with EVAR using Incraft (Cordis), Zenith LP/Alpha (Cook Medical Inc) and Ovation (Endologix) endografts. RESULTS 36 papers were evaluated, reporting results of 582 patients treated with Zenith device, 1211 with Incraft and 3449 with Ovation. During follow up, similar survival and freedom from reintervention rates were reported among the various types of endograft both at 1 and 3 years. The incidence of limb stenosis/kinking was significantly higher in patients treated with Zenith LP/Alpha (2.1%, P = 0.008), while the Incraft device had a significantly lower proportion of type III endoleaks (P < 0.001). CONCLUSIONS Long-term survival and freedom from reintervention rates were comparable among the three LPEs. The Cook Zenith device had the highest rates of limb stenosis/kinking, while the Incraft device had the lowest occurrence of type III endoleak. PROSPERO Registration number: CRD42022315875.
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Affiliation(s)
- Daniela Mazzaccaro
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Paolo Righini
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Matteo Giannetta
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marina Galligani
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Valentina Milani
- Scientific Directorate, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Alfredo Modafferi
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Giovanni Malacrida
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Giovanni Nano
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
- Department of Biomedical Sciences for Health, Università Degli Studi di Milano, Milan, Italy
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Wang Q, Wu J, Ma Y, Zhu Y, Song X, Xie S, Liang F, Gimzewska M, Li M, Yao L. Totally percutaneous versus surgical cut-down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair. Cochrane Database Syst Rev 2023; 1:CD010185. [PMID: 36629152 PMCID: PMC9832535 DOI: 10.1002/14651858.cd010185.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Abdominal aortic aneurysms (AAAs) are a vascular condition with significant risk attached, particularly if they rupture. Therefore, it is critical to identify and repair these as an elective procedure before they rupture and require emergency surgery. Repair has traditionally been an open surgical technique that required a large incision across the abdomen. Endovascular abdominal aortic aneurysm repairs (EVARs) are now a common alternative. In this procedure, the common femoral artery is exposed via a cut-down approach and a graft is introduced to the aneurysm in this way. This Cochrane Review examines a totally percutaneous approach to EVAR. This technique gives a minimally invasive approach to femoral artery access that may reduce groin wound complication rates and improve recovery time. However, the technique may be less applicable in people with, for example, groin scarring or arterial calcification. This is an update of the previous Cochrane Review published in 2017. OBJECTIVES To evaluate the benefits and harms of totally percutaneous access compared to cut-down femoral artery access in people undergoing elective bifurcated abdominal endovascular aneurysm repair (EVAR). SEARCH METHODS We used standard, extensive Cochrane search methods The latest search was 8 April 2022. SELECTION CRITERIA We included randomised controlled trials in people diagnosed with an AAA comparing totally percutaneous versus surgical cut-down access endovascular repair. We considered all device types. We only considered studies investigating elective repairs. We excluded studies reporting emergency surgery for ruptured AAAs and those reporting aorto-uni-iliac repairs. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. short-term mortality, 2. failure of aneurysm exclusion and 3. wound infection. Secondary outcomes were 4. major complications (30-day or in-hospital); 5. medium- to long-term (6 and 12 months) complications and mortality; 6. bleeding complications and haematoma; and 7. operating time, duration of intensive treatment unit (ITU) stay and hospital stay. We used GRADE to assess the certainty of evidence for the seven most clinically relevant primary and secondary outcomes. MAIN RESULTS Three studies with 318 participants met the inclusion criteria, 189 undergoing the percutaneous technique and 129 treated by cut-down femoral artery access. One study had a small sample size and did not adequately report the method of randomisation, allocation concealment or preselected outcomes. The other two larger studies had few sources of bias and good methodology; although one study had a high risk of bias in selective reporting. We observed no clear difference in short-term mortality between groups, with only one death occurring overall, in the totally percutaneous group (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.06 to 36.18; 2 studies, 181 participants; low-certainty evidence). One study reported failure of aneurysm exclusion. There was one failure of aneurysm exclusion in the surgical cut-down femoral artery access group (RR 0.17, 95% CI 0.01 to 4.02; 1 study, 151 participants; moderate-certainty evidence). For wound infection, there was no clear difference between groups (RR 0.18, 95% CI 0.01 to 3.59; 3 studies, 318 participants; moderate-certainty evidence). There was no clear difference between percutaneous and cut-down femoral artery access groups in major complications (RR 1.21, 95% CI 0.61 to 2.41; 3 studies, 318 participants; moderate-certainty evidence), bleeding complications (RR 1.02, 95% CI 0.29 to 3.64; 2 studies, 181 participants; moderate-certainty evidence) or haematoma (RR 0.88, 95% CI 0.13 to 6.05; 2 studies, 288 participants). One study reported medium- to long-term complications at six months, with no clear differences between the percutaneous and cut-down femoral artery access groups (RR 0.82, 95% CI 0.25 to 2.65; 1 study, 135 participants; moderate-certainty evidence). We detected differences in operating time, with the percutaneous approach being faster than cut-down femoral artery access (mean difference (MD) -21.13 minutes, 95% CI -41.74 to -0.53 minutes; 3 studies, 318 participants; low-certainty evidence). One study reported the duration of ITU stay and hospital stay, with no clear difference between groups. AUTHORS' CONCLUSIONS Skin puncture may make little to no difference to short-term mortality. There is probably little or no difference in failure of aneurysm exclusion (failure to seal the aneurysms), wound infection, major complications within 30 days or while in hospital, medium- to long-term (six months) complications and bleeding complications between the two groups. Compared with exposing the femoral artery, skin puncture may reduce the operating time slightly. We downgraded the certainty of the evidence to moderate and low as a result of imprecision due to the small number of participants, low event rates and wide CIs, and inconsistency due to clinical heterogeneity. As the number of included studies was limited, further research into this technique would be beneficial.
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Affiliation(s)
- Qi Wang
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Jing Wu
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | - Yanfang Ma
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China
| | - Ying Zhu
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Xiaoyang Song
- Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shitong Xie
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | - Fuxiang Liang
- Department of Cardiovascular Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Madelaine Gimzewska
- Academic Department of Vascular Surgery, Imperial College London, London, UK
| | - Meixuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
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Fujimura N, Ichihashi S, Obara H, Asakura T, Komooka M, Onitsuka S, Kurimoto Y, Kato H, Ohki T. Early Clinical Outcomes of Initial Launch of the Zenith Alpha Abdominal Endovascular Graft in Japan. J Endovasc Ther 2022; 30:241-249. [PMID: 35249411 DOI: 10.1177/15266028221079772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: This study retrospectively evaluated the 12-month outcomes of the Zenith Alpha Abdominal Endovascular graft (Zenith Alpha AAA, Cook, Inc, Bloomington, Indiana), which was launched partially in Japan in March 2019, starting with 9 selected sites. Methods: A retrospective analysis was performed of all endovascular aneurysm repairs (EVAR) for abdominal aortic aneurysms using the Zenith Alpha AAA. Late complications were defined as any aneurysm-related events occurring >30 days after EVAR, including an aneurysm sac enlargement of >5 mm and any reinterventions performed. Endoleaks without sac enlargement or reinterventions were excluded from late complications. Results: During the study period, 79 EVARs using the Zenith Alpha AAA were performed. The mean age was 76.6±6.9 years old, 91.1% of patients were male, and the mean aneurysm diameter was 51.1±7.5 mm. Instructions for use violation was observed in 27 patients (34.2%), most frequently being a severely angulated proximal neck (>60°). There were 4 intraoperative complications, including 2 unintentional partial renal artery coverages caused by the premature anchoring of the exposed suprarenal stent barb to the aortic wall, which was a result of the design change of the top cap deletion. Since it was a partial coverage without flow impairment and since renal stenting was unsuccessful, it was left untreated and had no subsequent renal function impairment. During the mean follow-up of 444±123 days, 74 patients completed 12 months of follow-up. Freedom from late complications at 12 months was 90.8%, which included 2 limb occlusions (2.5%). Of 71 patients with a 12-month computed tomography scan, there was only 1 type 1a endoleak (1.3%), 1 sac enlargement of >5 mm (1.3%), and an aneurysm sac shrinkage of >5 mm was observed in 42.2% of patients. There was no type 3 endoleak during the follow-up. Conclusions: This study demonstrated that the new generation of low-profile Zenith Alpha AAA has satisfactory early clinical outcomes, comparable to those obtained with the conventional Zenith endovascular graft. Long-term follow-up is needed to determine whether these favorable outcomes persist.
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Affiliation(s)
- Naoki Fujimura
- Department of Vascular Surgery, Saiseikai Central Hospital, Tokyo, Japan
| | - Shigeo Ichihashi
- Department of Radiology, Nara Medical University, Kashihara, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Toshihisa Asakura
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Masatoshi Komooka
- Department of Cardiovascular Surgery, Yao Tokushukai Hospital, Osaka, Japan
| | - Seiji Onitsuka
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Yoshihiko Kurimoto
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan
| | - Hiroaki Kato
- Department of Radiology, Mie University Hospital, Tsu, Japan
| | - Takao Ohki
- Department of Vascular Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Zhang S, Laubrie JD, Mousavi SJ, Avril S. 3D finite-element modeling of vascular adaptation after endovascular aneurysm repair. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2022; 38:e3547. [PMID: 34719114 DOI: 10.1002/cnm.3547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/27/2021] [Indexed: 06/13/2023]
Abstract
Aneurysm shrinkage is clinically observed after successful endovascular aortic aneurysm repair (EVAR). However, global understanding of post-operative aneurysm evolutions remains weak. In this work, we propose to study these effects using numerical simulation. We set up a 3D finite-element model of post-EVAR vascular adaptation within an open-source finite-element code, which was initially developed for growth and remodeling (G&R). We modeled the endograft with a set of uniaxial prestrained springs that apply radial forces on the inner surface of the artery. Constitutive equations, momentum balance equations, and equations related to the mechanobiology of the artery were formulated based on the homogenized constrained mixture theory. We performed a sensitivity analysis by varying different selected parameters, namely oversizing and compliance of the stent-graft, gain parameters related to collagen G&R, and the residual pressure in the aneurysm sac. This permitted us to evaluate how each factor influences post-EVAR vascular adaptation. It was found that oversizing, compliance or gain parameters have a limited influence compared to that of the residual pressure in the aneurysm sac, which was found to play a critical role in the stability of aneurysm after stent-graft implantation. An excessive residual pressure larger than 50 mmHg can induce a continuous expansion of the aneurysm while a moderate residual pressure below this critical threshold yields continuous shrinkage of the aneurysm. Moreover, it was found that elderly patients, with relatively lower amounts of remnant elastin in the arterial wall, are more sensitive to the effect of residual pressure. Therefore, these results show that elderly patients may present a higher potential risk of aortic sac expansion due to intra-aneurysm sac pressure after EVAR than younger patients.
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Affiliation(s)
- Shaojie Zhang
- Mines Saint-Étienne, Univ Lyon, Univ Jean Monnet, INSERM, U 1059 Sainbiose, Saint-Étienne, France
| | - Joan D Laubrie
- Mines Saint-Étienne, Univ Lyon, Univ Jean Monnet, INSERM, U 1059 Sainbiose, Saint-Étienne, France
| | - S Jamaleddin Mousavi
- Mines Saint-Étienne, Univ Lyon, Univ Jean Monnet, INSERM, U 1059 Sainbiose, Saint-Étienne, France
| | - Stéphane Avril
- Mines Saint-Étienne, Univ Lyon, Univ Jean Monnet, INSERM, U 1059 Sainbiose, Saint-Étienne, France
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Torsello G, Bertoglio L, Kellersmann R, Wever JJ, van Overhagen H, Stavroulakis K. One-Year Results of the INSIGHT Study on Endovascular Treatment of Abdominal Aortic Aneurysms. J Vasc Surg 2022; 75:1904-1911.e3. [PMID: 34995719 DOI: 10.1016/j.jvs.2021.12.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/16/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Endovascular repair of abdominal aortic aneurysms (AAA) using the INCRAFT™ AAA Stent Graft System was safe and effective in regulatory approval studies. We herein report on the 1-year results of a real-world clinical study. METHODS The INSIGHT study is a multi-center, prospective, open label, post-approval study conducted to continually evaluate the safety and performance of the INCRAFT ™ System. Between 2015 and 2016, 150 consecutive patients with AAA at 23 centers in Europe were treated with the device in routine clinical practice. The primary endpoint was freedom from major adverse events (MAEs), namely death, myocardial infarction (MI), cerebrovascular accident (CVA) and renal failure, within 30 days of the index procedure. Endpoint data were assessed by a core laboratory. The secondary endpoints included technical success at the conclusion of the procedure and clinical success. RESULTS All 150 patients studied (mean age: 73.6 ± 8.0 and 89.3% men) met the primary endpoint without MAEs at 30-day follow up. Technical success was achieved in 99.3% of patients without stent fractures at 30 days. Among the 146 patients eligible for 1-year follow-up, the MAE rate was 8.2%, i.e., 12 patients suffered 13 MAEs: CVA in 8, MI in 1, and 4 died (resulting in a 2.7% all-cause mortality rate). There were no reports of new onset renal failure requiring dialysis. Only 2.7% of patients had type I endoleak and no III endoleaks were identified through 1 year. The rate of clinical success at 1 year was 91.8%. CONCLUSIONS The 1-year results of this multicenter real-world study underscore the safety and effectiveness of endovascular treatment of AAA with the INCRAFT System in routine clinical practice.
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Affiliation(s)
- Giovanni Torsello
- Department of Vascular Surgery St. Franziskus Hospital, Muenster, Germany
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Richard Kellersmann
- Clinic and Polyclinic for General, Visceral, Vascular and Pediatric Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Jan J Wever
- Department of Vascular Surgery & Interventional Radiology , Haga Hospital, The Hague, the Netherlands
| | - Hans van Overhagen
- Department of Vascular Surgery & Interventional Radiology , Haga Hospital, The Hague, the Netherlands
| | - Konstantinos Stavroulakis
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany; Department of Vascular and Endovascular Surgery, Ludwig-Maximilian-University Hospital, Munich, Germany
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Hertault A, Bianchini A, Daniel G, Martin-Gonzalez T, Sweet B, Sgorlon G, Fabre D, Sobocinski J, Haulon S. Experience With Unfavorable Iliac Access When Performing Fenestrated/Branched Endovascular Aneurysm Repair. J Endovasc Ther 2021; 28:315-322. [PMID: 33554706 DOI: 10.1177/1526602821991125] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To review a single-center experience with fenestrated and branched endovascular aneurysm repair (f/bEVAR) in patients with challenging iliac anatomies. MATERIALS AND METHODS A retrospective review of the department's database identified 398 consecutive patients who underwent complex endovascular repair f/bEVAR between January 2010 and June 2018; of these, 67 had challenging accesses. The strategies implemented to overcome access issues were reviewed, using a dedicated scoring system to evaluate the access (integrating diameter, tortuosity, calcification, and previous open or endovascular repair). RESULTS In this subgroup of patients, the most common graft design was a 4-vessel fenestrated endograft (27, 40.3%). Hostile access was due to small diameter (<7 mm) in 25 patients (37.3%) and/or concentric calcifications in 19 patients (26.9%). Mean iliac diameter was 5.5±2.6 mm on the right side and 6.0±2.5 mm on the left side. Previous open or endovascular aortoiliac repair had been performed in 15 patients (22.4%), and 20 patients (29.9%) had a stent previously implanted in at least 1 iliac artery, resulting in the inability to perform standard fenestrated repair with access from both sides. Five patients (7.5%) had a single patent iliac access. Eight distinctive strategies were identified to overcome these access issues, including the use of preloaded renal catheters in the endograft delivery system, angioplasty, graft modification (branches instead of fenestrations or 4 preloaded fenestrations), a conduit via a retroperitoneal approach, iliac artery recanalization, and/or the multiple puncture technique. Technical success was achieved in 62 cases (92.5%). Four patients had access complications and 1 died in the early postoperative period of multiorgan failure. Median follow-up was 24.6 months (IQR 7.2, 41.3). Clinical success at the end of follow-up was achieved in 57 patients (85.1%). During follow-up, 14 patients died, including 4 from an aorta-related cause. CONCLUSION Dedicated strategies can be implemented to overcome hostile iliac access in patients with complex aneurysms when f/bEVAR is required. Typically, these maneuvers are associated with favorable outcomes.
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Affiliation(s)
- Adrien Hertault
- Vascular and Endovascular Surgery Department, Valenciennes Hospital, Valenciennes, France
| | - Aurélia Bianchini
- Vascular and Endovascular Surgery Department, Valenciennes Hospital, Valenciennes, France
| | - Guillaume Daniel
- Department of Vascular Surgery, Hôpital Privé Jean Mermoz, Lyon, France
| | | | - Birgit Sweet
- Vascular and Endovascular Surgery Department, Herzzentrum Bad Segeberg, Germany
| | - Giada Sgorlon
- Vascular and Endovascular Surgery Department, AULSS 4 Veneto Orientale, San Donà di Piave, Venice, Italy
| | - Dominique Fabre
- Aortic Centre, Hôpital Marie Lannelongue, Le Plessis-Robinson, INSERM UMR_S 999, Université Paris Sud, Paris, France
| | - Jonathan Sobocinski
- Aortic Center, Heart & Lung Institute, Lille University Hospital, Lille, France
| | - Stéphan Haulon
- Aortic Centre, Hôpital Marie Lannelongue, Le Plessis-Robinson, INSERM UMR_S 999, Université Paris Sud, Paris, France
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Lindsay T, Jazaeri O, Sherman SM, Saunders AT, Forbes TL, Lindsay T, Nelson W, Harlock J, Feezor R, Stone P, Jazaeri O, Akers D, Forbes T, Singh M, Fernandez J, Kougias P, Laskowski I, Hurie J, Lee CJ, Jain A, Papenhausen M, Oskin T, Simonian G, Mueller M, Parvanthaneni S, Tamaddon H, Bruen K, Rahini S, Mehta M, Nagpal S, Patel A, Kulwicki A, Ellozy S. Final results from a postmarket registry of an iliac leg graft with a continuous, spiral nitinol stent. J Vasc Surg 2020; 72:576-583.e1. [DOI: 10.1016/j.jvs.2019.10.078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
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11
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Abstract
CLINICAL/METHODICAL ISSUE New technical developments in endovascular aortic repair (EVAR) have broadened the range of patients eligible for minimally invasive aneurysm treatment. Optimization of delivery sheaths and catheters by considerable downsizing of diameters, increase of pushability and stability combined with flexibility are important parameters. PERFORMANCE Especially patients characterized by small and tortuous iliac access vessels can nowadays be treated by EVAR. Ease and effectiveness of applicability guarantee safety and quality improvement, which results in better treatment of patients. Progress in stent-graft design with integrated options for repositioning, active positioning and aneurysm sealing facilitate treatment of angulated vessel segments or hitherto unsuitable sealing zones. PRACTICAL RECOMMENDATIONS Interventionalists have to be familiar with all available stent-graft materials and techniques. Profound knowledge helps to choose the best material for a patient's individual anatomy, confident application and long-term satisfactory results.
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12
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Ramirez JL, Schaller MS, Wu B, Reilly LM, Chuter TAM, Hiramoto JS. Late graft failure is rare after endovascular aneurysm repair using the Zenith stent graft in a cohort of high-risk patients. J Vasc Surg 2019; 70:1456-1462. [PMID: 31147125 DOI: 10.1016/j.jvs.2019.02.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 02/24/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Device-specific data on the long-term efficacy of endovascular aneurysm repair (EVAR) are limited by the constant evolution of stent graft design. Whereas some modifications, such as barb-mediated fixation, probably enhance durability, others, such as thin-walled fabric, are of less certain benefit. The purpose of this study was to examine 15 years of a single-center experience of EVAR using the Zenith stent graft (Cook Medical, Bloomington, Ind). METHODS Retrospective analysis was conducted of 325 high-risk patients who underwent elective EVAR with Zenith stent grafts between October 1998 and December 2005 under a physician-sponsored investigational device exemption. Patients' charts and death registries were reviewed to identify late stent graft failures and causes of death. Late stent graft failures were defined as type I or type III endoleaks; enlarging aneurysm sac requiring revision; and limb kinking or occlusion, stent graft infection, renal artery occlusion, or aneurysm rupture occurring >30 days after the index procedure. RESULTS The mean age at treatment was 75.9 ± 7.4 years, and 300 of 325 (92%) were men. The mean aneurysm diameter was 60 ± 9 mm, and the median main body stent graft diameter was 28 mm (range, 22-32 mm). During a median follow-up time of 5.6 years (interquartile range, 2.6-8.7 years), there were six (2%) aneurysm-related deaths caused by the following: one stent graft infection, one infection of a femoral-femoral bypass graft placed after limb occlusion, one infection of a stent graft placed to treat a type IB endoleak, and three aneurysm ruptures. There were 19 (6%) late stent graft failures occurring at a median time of 4.0 years (range, 39 days-14.6 years) after the procedure. Patients with late stent graft failure were more likely to have had impaired renal function (creatinine concentration ≥2 mg/dL; 21% vs 6%; P = .03) and less likely to have had cardiac disease (42% vs 67%; P = .04) at the time of the index procedure. There was no significant association between late stent graft failure and age, sex, aneurysm size, stent graft diameter, diabetes, smoking, or lung disease. Kaplan-Meier estimated overall survival was 60% at 5 years, 29% at 10 years, and 12% at 15 years. Kaplan-Meier estimated freedom from aneurysm-related mortality was 98% at 5 years, 97% at 10 years, and 97% at 15 years. CONCLUSIONS Late-occurring stent graft failures and aneurysm-related death are rare after EVAR using the Zenith stent graft, especially in high-risk patients whose comorbidities diminish life expectancy.
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Affiliation(s)
- Joel L Ramirez
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Melinda S Schaller
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Bian Wu
- Department of Surgery, University of California, San Francisco, San Francisco, Calif; Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, Calif
| | - Linda M Reilly
- Department of Surgery, University of California, San Francisco, San Francisco, Calif; Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, Calif
| | - Timothy A M Chuter
- Department of Surgery, University of California, San Francisco, San Francisco, Calif; Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, Calif
| | - Jade S Hiramoto
- Department of Surgery, University of California, San Francisco, San Francisco, Calif; Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, Calif.
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13
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Vacirca A, Faggioli G, Pini R, Gallitto E, Mascoli C, Cacioppa LM, Gargiulo M, Stella A. The Outcome of Technical Intraoperative Complications Occurring in Standard Aortic Endovascular Repair. Ann Vasc Surg 2019; 56:153-162. [DOI: 10.1016/j.avsg.2018.08.092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/03/2018] [Accepted: 08/08/2018] [Indexed: 11/25/2022]
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14
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Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, Dick F, van Herwaarden J, Karkos C, Koelemay M, Kölbel T, Loftus I, Mani K, Melissano G, Powell J, Szeberin Z, ESVS Guidelines Committee, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Kolh P, Lindholt JS, de Vega M, Vermassen F, Document reviewers, Björck M, Cheng S, Dalman R, Davidovic L, Donas K, Earnshaw J, Eckstein HH, Golledge J, Haulon S, Mastracci T, Naylor R, Ricco JB, Verhagen H. Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2019; 57:8-93. [DOI: 10.1016/j.ejvs.2018.09.020] [Citation(s) in RCA: 873] [Impact Index Per Article: 174.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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15
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Deery SE, Shean KE, Pothof AB, O'Donnell TFX, Dalebout BA, Darling JD, Bodewes TCF, Schermerhorn ML. Three-Year Results of the Endurant Stent Graft System Post Approval Study. Ann Vasc Surg 2018; 50:202-208. [PMID: 29505865 DOI: 10.1016/j.avsg.2017.12.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 12/04/2017] [Accepted: 12/30/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Long-term data following endovascular aneurysm repair (EVAR) exist but are limited to endografts that are no longer in use. The aim of the ENGAGE Post Approval Study is to describe the long-term safety and effectiveness data following EVAR using the Endurant stent graft system. METHODS From August 2011 to June 2012, 178 patients were enrolled and treated with the Endurant stent graft system. Clinical and radiologic data were prospectively collected and analyzed. The primary end point was abdominal aortic aneurysm (AAA)-related mortality, and secondary end points were overall mortality, endoleak, secondary interventions, and device-related complications. Kaplan-Meier estimates were used for late outcomes. RESULTS A total of 178 patients underwent EVAR with the Endurant stent graft across 24 centers (82% men; median age 71, interquartile range [IQR] 66-79). Median aortic diameter was 55 mm (IQR 51-58 mm). There was a 98.9% technical success rate. Three-year clinical and radiographic follow-up data were available for 87% and 74% of patients, respectively. Median follow-up was 37 months (IQR 30-38 months). Three-year aneurysm-related mortality rate was 1.1%, with 2 deceased patients in the perioperative period. All-cause mortality rate at 3 years was 13%. No patients suffered from aneurysm rupture or underwent conversion to open repair through 3 years of follow-up. Only 11 patients (6.2%) had undergone reintervention at 3 years. Younger age was associated with reintervention (HR 3.3 per younger decade, 95% confidence interval 1.3-7.6, P < 0.01), but neck diameter, length, and angulation were not significantly associated with reintervention. CONCLUSIONS The Endurant stent graft system provides a safe, durable approach to treating infrarenal AAA. No patients experienced late rupture or aneurysm-related mortality, and only 1 in 16 patients underwent reintervention by 3 years. The rate of reintervention with the Endurant graft appears to be lower than other contemporary grafts, despite more liberal "Instructions For Use" parameters, but further research including direct graft comparisons will be necessary to guide appropriate graft selection.
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Affiliation(s)
- Sarah E Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Katie E Shean
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Alexander B Pothof
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Barbara A Dalebout
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jeremy D Darling
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Thomas C F Bodewes
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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16
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The Safety of Device Registries for Endovascular Abdominal Aortic Aneurysm Repair: Systematic Review and Meta-regression. Eur J Vasc Endovasc Surg 2018; 55:177-183. [DOI: 10.1016/j.ejvs.2017.11.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 11/12/2017] [Indexed: 01/01/2023]
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17
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Gender-Related Differences in Iliofemoral Arterial Anatomy among Abdominal Aortic Aneurysm Patients. Ann Vasc Surg 2017; 44:171-178. [DOI: 10.1016/j.avsg.2017.01.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 11/22/2016] [Accepted: 01/09/2017] [Indexed: 11/22/2022]
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18
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Third- versus Second-Generation Stent Graft for Endovascular Aneurysm Repair: A Device-Specific Analysis. Ann Vasc Surg 2017; 44:67-76. [DOI: 10.1016/j.avsg.2017.03.176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 03/01/2017] [Indexed: 01/16/2023]
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19
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‘t Mannetje YW, Cuypers PW, Saleem BR, Bode AS, Teijink JA, van Sambeek MR. Comparison of midterm results for the Talent and Endurant stent graft. J Vasc Surg 2017; 66:735-742. [DOI: 10.1016/j.jvs.2017.01.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 01/08/2017] [Indexed: 12/13/2022]
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20
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Lalys F, Daoudal A, Gindre J, Göksu C, Lucas A, Kaladji A. Influencing factors of sac shrinkage after endovascular aneurysm repair. J Vasc Surg 2017; 65:1830-1838. [DOI: 10.1016/j.jvs.2016.12.131] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 12/16/2016] [Indexed: 11/15/2022]
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21
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Gimzewska M, Jackson AIR, Yeoh SE, Clarke M. Totally percutaneous versus surgical cut-down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair. Cochrane Database Syst Rev 2017; 2:CD010185. [PMID: 28221665 PMCID: PMC6464496 DOI: 10.1002/14651858.cd010185.pub3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Abdominal aortic aneurysms (AAAs) are a vascular condition with significant risk attached, particularly if they rupture. It is, therefore, critical to identify and repair these as an elective procedure before they rupture and require emergency surgery. Repair has traditionally been an open surgical technique that required a large incision across the abdomen. Endovascular abdominal aortic aneurysm repairs (EVARs) are now a common alternative. In this procedure, the common femoral artery is exposed via a cut-down approach and a graft introduced to the aneurysm in this way. This review examines a totally percutaneous approach to EVAR. This technique gives a minimally invasive approach to femoral artery access that may reduce groin wound complication rates and improve recovery time. The technique may, however, be less applicable in people with, for example, groin scarring or arterial calcification. This is an update of the review first published in 2014. OBJECTIVES This review aims to compare the clinical outcomes of percutaneous access with surgical cut-down femoral artery access in elective bifurcated abdominal endovascular aneurysm repair (EVAR). SEARCH METHODS For this update the Cochrane Vascular Information Specialist (CIS) searched their Specialised Register (last searched October 2016) and CENTRAL (2016, Issue 9). We also searched clinical trials registries and checked the reference lists of relevant retrieved articles. SELECTION CRITERIA We considered only randomised controlled trials. The primary intervention was a totally percutaneous endovascular repair. We considered all device types. We compared this against surgical cut-down femoral artery access endovascular repair. We only considered studies investigating elective repairs. We excluded studies reporting emergency surgery for a ruptured abdominal aortic aneurysm and those reporting aorto-uni-iliac repairs. DATA COLLECTION AND ANALYSIS Two review authors independently collected all data. Owing to the small number of trials identified we did not conduct any formal sensitivity analysis. Heterogeneity was not significant for any outcome. MAIN RESULTS Two studies with a total of 181 participants met the inclusion criteria, 116 undergoing the percutaneous technique and 65 treated by cut-down femoral artery access. One study had a small sample size and did not adequately report method of randomisation, allocation concealment or pre-selected outcomes. The second study was a larger study with few sources of bias and good methodology.We observed no significant difference in mortality between groups, with only one mortality occurring overall, in the totally percutaneous group (risk ratio (RR) 1.50; 95% confidence interval (CI) 0.06 to 36.18; 181 participants; moderate-quality evidence). Only one study reported aneurysm exclusion. In this study we observed only one failure of aneurysm exclusion in the surgical cut-down femoral artery access group (RR 0.17, 95% CI 0.01 to 4.02; 151 participants; moderate-quality evidence). No wound infections occurred in the cut-down femoral artery access group or the percutaneous group across either study (moderate-quality evidence).There was no difference in major complication rate between cut-down femoral artery access and percutaneous groups (RR 0.91, 95% CI 0.20 to 1.68; 181 participants; moderate-quality evidence); or in bleeding complications and haematoma (RR 0.94, 95% CI 0.31 to 2.82; 181 participants; high-quality evidence).Only one study reported long-term complication rates at six months, with no differences between the percutaneous and cut-down femoral artery access group (RR 1.03, 95% CI 0.34 to 3.15; 134 participants; moderate-quality evidence).We detected differences in surgery time, with percutaneous approach being significantly faster than cut-down femoral artery access (mean difference (MD) -31.46 minutes; 95% CI -47.51 minutes to -15.42 minutes; 181 participants; moderate-quality evidence). Only one study reported duration of ITU (intensive treatment unit) and hospital stay, with no difference found between groups. AUTHORS' CONCLUSIONS This review shows moderate-quality evidence of no difference between the percutaneous approach compared with cut-down femoral artery access group for short-term mortality, aneurysm exclusion, major complications, wound infection and long-term (six month) complications, and high-quality evidence for no difference in bleeding complications and haematoma. There was a difference in operating time, with moderate-quality evidence showing that the percutaneous approach was faster than the cut-down femoral artery access technique. We downgraded the quality of the evidence to moderate as a result of the limited number of studies, low event numbers and imprecision. As the number of included studies were limited, further research into this technique would be beneficial. The search identified one ongoing study, which may provide an improved evidence base in the future.
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Affiliation(s)
- Madelaine Gimzewska
- Usher Institute of Population Health Sciences and Informatics, The University of EdinburghCochrane VascularTeviot PlaceEdinburghUKEH8 9AG
| | - Alexander IR Jackson
- University Hospital Southampton NHS Foundation TrustSouthampton General HospitalTremona RoadSouthamptonUKS016 6YD
- University of SouthamptonClinical and Experimental Sciences Academic UnitSouth Academic Block, Mailpoint 801Southampton General Hospital, Tremona RoadSouthamptonUKS016 6YD
| | - Su Ern Yeoh
- The University of EdinburghCollege of Medicine and Veterinary MedicineEdinburghUKEH16 4TJ
| | - Mike Clarke
- Freeman HospitalNorthern Vascular CentreFreeman RoadNewcastle upon TyneUKNE7 7DN
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Verzini F, Romano L, Parlani G, Isernia G, Simonte G, Loschi D, Lenti M, Cao P. Fourteen-year outcomes of abdominal aortic endovascular repair with the Zenith stent graft. J Vasc Surg 2017; 65:318-329. [DOI: 10.1016/j.jvs.2016.07.117] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 07/19/2016] [Indexed: 11/24/2022]
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23
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Schoretsanitis N, Georgakarakos E, Argyriou C, Ktenidis K, Georgiadis GS. A critical appraisal of endovascular stent-grafts in the management of abdominal aortic aneurysms. Radiol Med 2017; 122:309-318. [DOI: 10.1007/s11547-017-0724-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 01/03/2017] [Indexed: 11/30/2022]
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24
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Smeds MR, Charlton-Ouw KM. Infrarenal endovascular aneurysm repair: New developments and decision making in 2016. Semin Vasc Surg 2016; 29:27-34. [PMID: 27823586 DOI: 10.1053/j.semvascsurg.2016.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
New developments in infrarenal abdominal aortic aneurysm stent-graft devices have made more patients eligible for endovascular aneurysm repair (EVAR). Recent US Food and Drug Administration approval for fenestrated endograft repair and impending approval for iliac branch devices extend the proximal and distal landing zones. Better deployment systems allow for partial deployment of endografts to facilitate repositioning, and more flexible designs allow for treatment of angulated infrarenal aneurysm necks and tortuous iliac arteries. New iterations of endografts have smaller delivery catheter diameters, which facilitate traversal of smaller access vessels. Long-term outcomes data are still accumulating and it remains to be seen whether EVAR for this expanded-indication abdominal aortic aneurysms anatomy has the same durability as standard EVAR. More options for repair also mean vascular surgeons must select the best EVAR device based on each patient's abdominal aortic aneurysm anatomy.
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Affiliation(s)
- Matthew R Smeds
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Arkansas for Medical Sciences, 4301 West Markham Street #520-2, Little Rock, AR 72205-7199.
| | - Kristofer M Charlton-Ouw
- Division of Vascular and Endovascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), TX
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25
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O'Mara JE, Bersin RM. Endovascular Management of Abdominal Aortic Aneurysms: the Year in Review. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:54. [PMID: 27376647 DOI: 10.1007/s11936-016-0470-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OPINION STATEMENT Endovascular aneurysm repair (EVAR) has become the predominant method of treatment for abdominal aortic aneurysms (AAA). The use of conscious sedation with local anesthesia and percutaneous femoral access has further decreased the morbidity of the procedure. Current devices can more effectively manage increasingly "hostile" aneurysm necks, while chimney grafts or dedicated fenestrated stent-grafts can be used for juxta-renal disease with favorable results. However, endovascular repair does present a new set of challenges, and endoleaks remain an area of concern. While there is general consensus that type I and type III endoleaks require treatment, type II endoleaks are the topic of ongoing research and debate. Development of devices and techniques to prevent and treat endoleak continues to progress. Advances in contrast-enhanced ultrasound are reducing reliance on computed tomography for post-operative monitoring. This is an important step in this population at high risk for the development of kidney failure. Despite these many innovations, further research is needed to optimize the care of patients with AAA.
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Affiliation(s)
- John E O'Mara
- Swedish Medical Center, Heart and Vascular Institute, Suite 680, 550 17th Ave, Seattle, WA, 98122, USA. John.O'
| | - Robert M Bersin
- Swedish Medical Center, Heart and Vascular Institute, Suite 680, 550 17th Ave, Seattle, WA, 98122, USA
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26
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Maudet A, Daoudal A, Cardon A, Clochard E, Lucas A, Verhoye JP, Kaladji A. Endovascular Treatment of Infrarenal Aneurysms: Comparison of the Results of Second- and Third-Generation Stent Grafts. Ann Vasc Surg 2016; 34:95-105. [DOI: 10.1016/j.avsg.2015.12.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 12/04/2015] [Accepted: 12/20/2015] [Indexed: 12/20/2022]
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27
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Clough RE, Haulon S. Commentary on 'Morphological Differences in the Aorto-iliac Segment in AAA Patients of Caucasian and Asian Origin'. Eur J Vasc Endovasc Surg 2016; 51:790. [PMID: 27150799 DOI: 10.1016/j.ejvs.2016.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/13/2016] [Indexed: 10/22/2022]
Affiliation(s)
- R E Clough
- Aortic Centre, Hôpital Cardiologique, CHRU Lille, France; National Institute for Health Research (NIHR) Comprehensive Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, UK.
| | - S Haulon
- Aortic Centre, Hôpital Cardiologique, CHRU Lille, France
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